Polycystic ovarian syndrome or PCOS: involves having multiple cysts on the ovaries and other physical findings associated with an abnormal functioning of the hypothalamic-pituitary-ovarian axis.
At least twelve cystic follicles per ovary in at least one ovary.
Presentation:
Hyperandrogenism,
Anovulation, and
Menstrual difficulties.
Incidence and Prevalence
Common endocrine disease in women of reproductive age,
Prevalence at any given point in time of about ten percent,
Racial variability in different ethnicities,
Affects women of reproductive age,
Probably begins prior to the onset of menarche,
Not commonly diagnosed until symptoms of hirsutism and irregular menses manifest itself
Predisposing Factors
Family history,
Diabetes and
Signs and Symptoms
Irregular periods,
Lack of ovulation,
Pelvic pain if the ovaries are enlarged,
Hirsutism,
Obstructive sleep apnea,
Diabetes mellitus with hyperinsulinemia,
Obesity,
Metabolic syndrome, and
Clinical Presentation
NIH Criteria:
Oligo-ovulation or anovulation: amenorrhea or oligomenorrhea,
Hyperandrogenism or hyperandrogenemia, and
Exclusion of other possibilities behind the symptoms.
ESHRE (European Society for Human Reproduction and Embryology and the ASMR (American Society for Reproductive medicine) Criteria, at least two of the following three findings must be present
Anovulation or oligo-ovulation: decreased frequency of menstruation,
Clinical evidence of excess androgens or Laboratory evidence of elevated androgens,
Polycystic ovaries on a pelvic ultrasound.
Etiology
Abnormalities in the metabolism of estrogen and testosterone, and
Abnormality in the control of the production of androgens: high levels of androstenedione, testosterone, and dehydroepiandrosterone sulfate (DHEA-S) in the bloodstream. Normal androgen levels are possible.
Associated with insulin resistance and hyperinsulinemia:
The elevated insulin level may secondarily affect the effects of gonadotropins on the female ovaries,
May also cause suppression of the liver’s ability to produce sex-hormone binding globulin: increasing the androgen levels.
Relate to the levels of adiponectin in the body.
Adiponectin: Hormone secreted by fat cells: regulates the metabolism of lipids and the levels of glucose in the body
PCOS have decreased adiponectin levels.
Responsible for the elevation of lipids and
High levels of plasminogen activator inhibitor-1 (PAI-1). High levels of PAI-1 increase the risk for intravascular thrombosis.
Pathology
Grossly, both ovaries are enlarged,
Avascular, smooth, and thickened capsule surrounding the ovarian stromal cells
Microscopy:
Hyperplasia of the stromal cells surrounding multiple follicles arrested during their development, and
Follicles are in various stages of atresia.
Treatment and Management
Hirsutism and menstrual irregularities:
Eflornithine with laser therapy to remove the hair excess on the body,
Hormonal contraceptives: Low dose birth control pill: reduce acne and hirsutism
Couples desiring a pregnancy: Clomiphene citrate: stimulate ovulation.
High blood sugar and hyperinsulinemia:
Metformin: Controls type 2 diabetes,
Decrease androgen levels, and
Aid in weight loss
Lifestyle changes
Weight loss and exercise:
Decrease the chances of having diabetes mellitus
Reduce androgen levels,
Improve anovulation and restore ovulatory cycles.
Excess Androgen:
Prednisone or another corticosteroid:
Suppresses adrenal function, i.e. lower the blood levels of androgens.
Anti-Androgens:
Spironolactone, finasteride, and leuprolide
Reduce the adverse effects of androgens
Acne:
Topical acne preparations (benzoyl peroxide or tretinoin cream),
Antibiotic therapy, or
Isotrentoin (Accutane), which is given orally for severe acne.
Complications
Higher risk of developing:
Cerebrovascular disease (strokes),
Cardiovascular disease (heart attacks).
Elevated LDL-cholesterol levels
Forty percent develop insulin resistance as part of their disease state.
Increased risk for endometrial hyperplasia because of anovulation:
increased risk for later developing endometrial carcinoma.
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